Life continues...

Although a majority of the patients I see here come with chronic gastritis with acid reflux, with Ascaris Lumbricoides (as has 25% of the world’s population), or with a simple throat infection, others, mainly those who have not been to a doctor in years – if ever – come with a list of ailments pointing to the pain across the globe of their bodies like a game of Heads-Fingers-Knees-and-Toes (knees and toes). And then there are the more interesting cases, about which I will write.

A young girl of 9 years came to our consult room last Wednesday, complaining of abdominal pain. Her father told us that the pain began on the previous Friday, was most intense on Saturday and was so bad that she had to walk doubled-over and was vomiting. She had felt better since then and had minimal pain that continued in the lower right part of her belly. Although this is not the typical picture of appendicitis that we see in the US where a patient comes in after pain for less than a few days or often less than a day, the very dangerous diagnosis of a ruptured appendix was still a primary concern of mine. Martha, the other young doctor I was working with shared the concern and our physical diagnosis tests for appendicitis were all positive so we admitted the patient to watch overnight after making the surgeon aware of her. During the night, our surgeon decided to operate and sure enough it was a ruptured appendix. Had we not decided to admit her, there is a real possibility that she would not be alive to walk out of the hospital this past weekend.

Another night when I was on call with another doctor, Juan, we were called to the hospital early in the night for an emergency visit. When we arrived, the patient was still in a car outside, as if often typical of how we find the emergency patients. There were about 10 people standing in the back of the pick-up truck and three men in the front. The patient was clearly the one in the middle, a young man in his early 20’s with his eyes closed and the look of someone who had drank far too much for his body. Juan reached in with my stethoscope first and then using a flashlight checked the man’s eyes. Then he told me to check the man over. When I pressed my stethoscope against his chest I heard something I honestly have not heard too often from a person’s chest – nothing. To confirm the diagnosis, I checked his eyes to see if his pupils reacted to light but they did not. The young man was dead. It turns out the driver had found him hanging from an electrical pole. Juan said “no,” to the guys up front and they questioned him, “No?” they asked. “No,” Juan said, shaking his head and they drove off. The next morning, we were woken before 8 am to find a group of 12 guys, this man’s brothers and family members who wanted to speak to us. My first instinct was that they wanted trouble but there is very little of which you can accuse a doctor of when a patient arrives dead. They were very polite, however, and asked for a paper pronouncing their relatives death. They all thanked us and we shook a dozen hands before we went back to the house to shake the stiffness of the night from our shoulders and to eat some breakfast.

Dia de los Medicos - a little party the Sisters through to honor the doctors!

This weekend I went alone to Comitan, a small worker’s city without the glory of San Cristobal and without the tourists for good reason. Still they have a few hotels, a town center, a few museums, a theater and a place that shows a movies twice a day.

The circa 1910 Pharmacy from the Museum of Dr. Belisario Dominguez' house in Comitan. A diligent man, he worked all day, took a 15 minute nap at 12 noon, drank one bottle of a German nutrition malt and returned to work, often writing to his pharmacy "On my tab" for the patients who could not afford to pay.

I drove the hour and half with Oscar, a jovial man in his early 30’s who has the longest history at San Carlos hospital and is half laboratory boss, half high school chemistry teacher, and all soccer player. In Comitan, I walked around enough to get lost, ate some pizza, and did some reading. The next day, set on seeing the waterfalls at Chiflan, I wound up at the Lakes of Montebello. There are 31 lakes of different colors in an area about 1 hour south of Comitan. The day had been a blue and warm, but by the time my collectivo arrived, clouds had pulled over the sky and the air turned cold and threatened rain from across the horizon. They let me off beside one of the lakes and I walked down to the water. Aside from an older couple that had gotten off with me, I was alone at the lake and sat there on its edge, quite sadly, and looked over my left shoulder into Guatemals as I shivered in my long sleeve shirt. Then, pulling out a Snicker’s bar I’d been saving over the last 5 weeks that had the same tortured look to it that fit the day so well, I thought back on how I’d gotten here. The empty cold lake with a row of closed kiosks reminded me of Coney Island in the winter, a place that only a few people like my brother can romanticize what they see back to how it was in their memory or imagination more than 50 years earlier; before the gangs and drug needles, before it’s abandonment and paltry sum of re-inhabitants – the dreamers and the local families who cannot afford to go as far as Jones beach.

Content that I did not need to come so far to have a Coney Island without even a Nathan’s dog, I walked on to the next lake. On my walk, the sky woke up, clouds blew off, revealing a brilliant blue, and the sun warmed up the day so much I was sweating as I walked on. At the next lake, I met a young married couple on vacation from Guatemala. We talked for a while and after I’d walked off to find my collective back to Comitan, they came after me in their car and said “Vamonos! Let’s go.” I had thought they would drive me the kilometer to the highway but then they asked me where I wanted to go. We went to five more lakes of different colors and then took a special path down to a couple caves by a rapidly flowing river. The path to the caves was lined with an entire market of fruit trees. We at our way down it, first Guayabas, then Mispero ( a grape-sized fruit that tasted like molded lemonade) and then Limes, and finally Naranjita (mandarin-sized oranges that taste like California oranges that had died somewhere in Oklahoma but continued on to New York anyway).

The caves were full of mud and Freddy and I slid down along logs that he had aligned to explore. Since it was truly down that we slid, I worried it was a one way trip for us both but I could not translate that effectively so we went deeper into the dark cave. I was reminded of our caves back home with the lighted guard rails and cement pathways from which you are not allowed to stray. This was our cave as long as we were in it and very beautiful from what I could see. All the while, I looked for bats as I had seen in another cave but could not see any. Then hand in hand, we made it back out and they drove me in their beautiful SUV with air conditioning (a treat!) to Comitan and from my hotel to the collective station to return to Altamirano. My luck in meeting them and their hospitality brightened my day and reminded me what I love so much about traveling: the unexpected friendships that somehow align themselves with the unknown agenda of the day.

More patient stories soon, I promise. I really appreciate the comments I have received. If you would like to know more about something, please let me know and I will try to include it in my next post. Oh and if anyone has any advice as to what to do about Cancun and the fact that Ines and I had planned to stay there before she flies home from Cancun in less than 4 weeks let me know! If your advice is stay away, yeah, I heard that already.

Floating Away...

I want to reassure anyone concerned that although the flooding has been devastating in the southern parts of Chiapas – in border towns such as Tapachula -- and across much of Guatemala, we had only seen 3 days of heavy rains in Altamirano. I have spent the last five days traveling with my mom and saw none of the floods that are covered on the news. Of course, when my mom came down to Tuxtla, she realized her true purpose was to deliver mail and my scotch. It really is difficult to find good Scotch outside of the US (and of course, Scotland). Laphroaig happens to be the best and well worth the effort of being funneled into a plastic water bottle and flown 2000 miles!

From Tuxtla we took a cab to San Cristobal. The distance between two of Chiapas’ larger cities, the former with the airport and the latter with the culture is a 1 ½ hour ride along the mountains because the express highway all the guidebooks talk about never opened. It seems the bridge of the express highway collapsed one month before they were going to cut the ribbon. San Cristobal remains one of my favorite cities in the world. It has a slow, lazy feel to it with perfectly cool weather and an occasional rain in the afternoon that leaves the cobblestone streets, once the sun returns, glowing like broken silver. There are coffeehouses to explore along with museums, markets, jewelry shops, juice bars, and scores of backpackers and strays from around the world who come to stay or pass through on their way to Palenque. There is Indian food, Sushi, American, and plenty of Mexican cuisine. Tours go out daily to all parts of Chiapas as well as down to Guatemala. If you ever choose to visit, you can stay in a hostel, a Posada, or a hotel, and there is always internet available somewhere around the corner.

We went to the mall on the outskirts of town to see Plan de Vuelo (Flight Plan) in a theater whose screen was at least as big as the largest I’ve seen in the States. I was really hoping it was in English with Spanish subtitles so my mind could take a break from twisting my brain around every word. Then the movie began and there is Jodie Foster, speaking German! If anyone has seen the movie, you would know the rest of the film is in English. The whole movie experience was a pleasant treat. Three hours from Altamirano, San Cristobal happens to have the closest movie theater. On the following morning, we took a tour of two nearby towns with very different indigenous cultures; San Juan Chamula and Zinacantan. In both towns, visitors who take pictures of religious rites get their cameras confiscated. In Chamula, the old catholic church has become a cove for indigenous rites. Inside, the pews have been removed and the flooring is covered in pine needles that are replaced weekly. Locals come with their chicken eggs to roll over their bodies or live chickens to sacrifice as well as candles to light all over the floor; all in the name of medicine or prayer to their Catholic saints. Outside the church, there are two markets – one for the townspeople and the other for the tourists in which some of the best of Chiapan textiles can be purchased. The vibrant reds, yellows, and blues line the corridors of the market making the experience of walking through the market to a color gourmand as sweet as the taste of Laphroaig to a Scotch gourmand.

In Palenque for the second time, I took my mom by taxi to the Misol-Ha waterfalls. When we arrived, we were nearly the only ones there, and I quickly went down the wooden trail that led across the wet rocks behind the falls to explore. Where the path ends, I climbed down on the rocks and across, still under the falls, where exists a set of stairs with an incredibly strong force of water gushing down them. Along the stairs, a rope is provided to help pull me up the stairs and not down the falls. At the top, following a Mexican guy who waited there, I climbed about 90 feet into a dark cave, around rocks and in calf-deep water to the back where a nice waterfall can be seen with a flashlight and bats hang from the ceiling. After that adventure, I navigated back around to the face of the over 100 foot high falls, which are now fuller than usual after several hard days of rain and dove into the refreshing water from its shoreline. The current in the pool below the falls was very strong and though I approached the falls, I decided it was best to pull myself along another rope which crossed the water. It was a truly beautiful place to be and I look forward to returning and sharing the experience.

Today I am back in Altamirano and my mom has returned to Tuxtla. I will start seeing patients on my own this afternoon. I am not worried about the medical part, but the idea of missing some important part of the history makes me a little nervous. Scotch aside, it was good to see my mom.

Altamirano, a demi-heaven in this Adventure

I arrived in Altamirano last Sunday not knowing what I was going to do, where I was going to live, if the town had hotels or much more. But I guess that is part of the adventure. Altamirano is a small dust town of mostly one-story buildings with little to its reputation besides its propinquity to Ocosingo (gateway to San Cristobal to the East and Palenque to the Northwest) AND if you search google for it, its research from the hospital here. There are three hotels, ranging from ten to fifteen dollars per night, several panaderias (bread stores), a central market and several chicken-beans-or-rice restaurants. Naturally, being thrifty to the point of stupidity, I chose the 10 dollar hotel (well, it is difficult to say if the more expensive ones - perhaps the 1 star one – would have made a difference. Needless to say, I had a room with a bathroom and supposedly hot water which I shared with over a dozen cockroaches (until I murdered them all!!!) . Oooh Ooh ha ha ha!

The following morning, I walked to the hospital and was welcomed into the doctors’ quarters and after a wonderful breakfast, went to meet the Sister in charge who with some worry and hesitation allowed me to stay for my three months. Yay! The hospital is a beautifully designed series of buildings connected by a covered walkway lined with huge flowers and gardens. It has an operating room, a delivery room and maternity suite, a pediatric wing and a neonatal wing and five consult rooms. I started my day in surgery for a suspected appendicitis which turned out to be ascaris lumbricoides. We removed over a pound of pencil-sized worms from this man’s intestines and I got my first gross exposure to the ubiquity of parasitosis here. In the afternoon, we removed a large necrotic area of skin from a young man who had been bitten by what is suspected to be a spider. I do not plan to use more detail for what is most likely viewed as fairly disgusting.

We work from 9 to 2 and then from 5 to 7 hospital time. The hospital does not honor daylight savings because the indigenous people do not either. Therefore, 9am hospital time is 10 am Mexico time and 11 am back home in New York. The dormitories here consist of a ranch house with one side for women and the other side for men. My quarters has 3 beds in my room and two other rooms connected. It is quite comfortable and tranquil here when I try to forget the fact that a tarantula was found in someone’s bed on my first night here. They kept it in a jar to show everyone. Sorry, no picture! The kitchen staff cooks for the doctors and the hospital workers. It is usually some variety of eggs for breakfast and then an assortment of beans, rice, pasta, cheese, tortillas, and chicken or ham for the other meals. We eat together in a dining room/ living room/library area and I am quickly making new friends. The doctors here range in age from 24 to their mid-thirties. No one speaks English, which is of obvious frustration and benefit to me, and everyone is very friendly and helpful.

I have spent the rest of my week in consults with several different doctors. We work together a lot better than I’ve seen in the states. The nurses are all indigenous women who speak Spanish and Tzeltal, the local dialect spoken by at least 75% of our patients. It is, in fact, unusual to me to see nurses smiling and doctors joking around so much but it makes the day go so much faster. Everyone says good morning and good afternoon, the patients are in general very grateful, thanking and shaking our hands as they leave, and the sisters oversee the hospital’s daily matters without intruding too much. One sister even is our anesthesiologist (quite a funny site to see an old nun with a tube in her ear that goes down the patient’s esophagus to listen to the heart sounds intubating and administering anesthesia!) This one doctor, Juan, likes to speak the patients in English when he is with me, saying “Sit down” and “What the problem?”

I have seen a lot of gastritis, a consequence of their diet of coffee and very spicy foods, parasitosis, and then unusual lumps, bumps, and bites. I have been working hard to learn the names of medicines and medical terms in Spanish and I am already at the point where I am doing the interview and the physical as well as occasionally writing the note. It is likely that in another week I will start seeing patients on my own. We have a lab with a range of capabilities, ultrasound, and basic radiography. What we are lacking, diagnostic capabilities now viewed as necessities in the US, like Computer Tomography, are frustratingly noted in my head when I think of them as informative. But that is why I came down here; to learn medicine without them. There was a day not too long ago when Aortic Aneurysms and tumors were hypothesized to be present and found only post-mortem. Surely we have gained a lot in our medical approach as we have integrated technology but we have lost a lot as well. There was a day when doctors ran around the hospital doing their own blood smears and lab tests, palpating and percussing their patients bodies and often learning as much as we learn after waiting for our blind CTs and chemical function tests to come back. In gaining and losing, just like how we try to save time, we end up roughly where we started. Maybe by improving my clinical diagnostic skills, I can wind up a little ahead, even in the busy emergency room. At least, that is my hope.

Los Medicos